heart and neck

• McGill Pain Scale


  A rigorously tested scientific pain scale. Overall score is determined by compiling various numerical and cross-reference descriptive words, allowing direct comparison across different conditions.
• Numeric Pain Scale


  Patients are asked to circle the number between 0 and 10, 0 and 20 or 0 and 100 that fits best to their pain intensity. Zero usually represents 'no pain at all' whereas the upper limit represents 'the worst pain ever possible'.
• Wong-Baker Pain Scale


  A method for someone to self-assess and effectively communicate the severity of pain they may be experiencing. The scale contains a series of six faces ranging from a happy face at 0 to indicate "no hurt" to a crying face at 10 to indicate "hurts worst."
• Pain Assessment Acronym


  Precipitating and relieving factors, Quality, Radiation, Site and Severity, Timing and Treatment history
• Pain Levels


  • No Pain
  • Mild
  • Moderate
  • Severe
• Head-to-Toe Assessment Techniques


  • Inspection: Look & Smell
  • Palpation: Feel texture and consistency with palms on finger tips
  • Percussion: Tap to access dullness or tympany
  • Auscultation: Listen for Sounds
• Vital Signs


  Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR), Temperature (T), Oxygen (O2)
• Blood Pressure


  Systolic - 120, Diastolic - 80, Hypotension - low blood, Hypertension - high blood
• Heart Rate


  60-100BPM, Bradycardia - less than 60, Tachycardia - greater than 100
• Respiratory Rate


  12-20 breaths per minute, Bradypnea - less than 12 b/m, Tachypnea - greater than 20 b/m
• Temperature


  97.8-99°F / 36.5-37.2°C, Hypothermia - <95°F / 35°C, Hyperthermia - >104°F / 40°C
• Oxygen


  95-100%, Hypoxemia - low oxygen levels
• Pain Scale


  Subjective data given by the patient
• Priority Intervention


  • Airway, Breathing, Circulation, Disability
• General & Health History


  • Subjective (What the patient says...)
  • Health History
  • Family History
  • Chief Complaint
  • Objective (What you see/measure...)
  • Behavior and mood
  • Appears stated age
  • Hygiene and nourishment level
  • Posture and mobility
  • Level of consciousness (Is the patient alert? or oriented?)
• Equipment needed for heart and neck vessels assessment

  • Stethoscope with bell diaphragm
  • Small pillow
  • Penlight or movable exam light
  • Watch with second hand
  • Two centimeter rulers
• Preparation


  1. Gather equipment

  2. Explain procedure to client

  3. Assist the client to put on a gown
• Jugular venous pulse


  Inspection of the jugular venous pressure pulse
• Inspect jugular venous pulse

  1. Stand on the right side of the client

  2. Client in supine position with torso elevated 30-45 degrees

  3. Head and torso on same plane

  4. Ask client to turn head slightly left

  5. Shine tangential light source onto neck
• Jugular venous pulse assessment

  • Important for determining hemodynamics of the right side of the heart
  • Level of jugular venous pressure reflects right atrial (central venous) pressure and right diastolic filling pressure
• Normal jugular venous pulse


  Not normally visible with client sitting upright
• Abnormal jugular venous pulse

  Fully distended jugular veins with client's torso elevated more than 45 degrees indicate increased intracranial pressure<|>Right sided heart failure raises pressure thus raising jugular venous pressure
• Measure jugular venous pressure

  1. Evaluate by watching for distention of the jugular vein

  2. Position client supine with head of bed elevated 30, 45, 60 and 90 degrees

  3. Turn client's head slightly away from side being evaluated

  4. Use tangential lighting to observe for distention, protrusion or bulging
• Normal jugular venous pressure


  Jugular vein should not be distended, bulging, or protruding at 45 degrees
• Abnormal jugular venous pressure

  Distention, bulging, or protrusion at 45, 60 or 90 degrees may indicate right sided heart failure
• Auscultate carotid arteries for bruits

  1. Place bell of stethoscope over carotid artery

  2. Ask client to hold breath to avoid breath sounds
• Normal carotid auscultation


  No blowing or swishing or other sounds heard
• Abnormal carotid auscultation


  A bruit, a blowing or swishing sound caused by turbulent blood flow through a narrowed vessel is indicative of occlusive arterial disease
• Palpate carotid arteries


  Place pads of index and middle fingers medial to sternocleidomastoid muscle
• Normal carotid palpation


  Pulses equally strong<|>Pulse amplitude 2+ or normal with no variation from beat to beat<|>Arteries are elastic and no thrills are noted<|>Contour is normally smooth
• Abnormal carotid palpation


  Pulse inequality may indicate arterial constriction or occlusion in one carotid<|>Weak pulse may indicate hypovolemia, decreased cardiac output<|>Bounding firm pulse may indicate hypervolemia and increased cardiac output<|>Thrills may indicate narrowing of artery
• Inspect precordium for visible pulsations


  Client in supine position with HOB elevated 30-45 degrees
• Normal precordium inspection


  Apical pulse may or may not be visible, if apparent it would be in mitral area, left midclavicular line, fourth or fifth intercostal space
• Abnormal precordium inspection


  Pulsations other than the apical pulsation are considered abnormal and should be evaluated<|>A heave or lift may occur as the result of an enlarged ventricle from an overload of work
• Palpate apical pulse


  1. Locate in mitral area (4th or 5th ICS at MCL)

  2. Use palmar surfaces of hand, then one finger for more accurate palpation
• Normal apical pulse


  Palpated in mitral area, size of a nickel (1-2 cm)<|>Amplitude is small, like a gentle tap<|>Duration is brief, lasting through first two thirds of systole
• Abnormal apical pulse


  Impossible to palpate in clients with pulmonary emphysema<|>If larger than 1-2 cm, displaced, more forceful or of longer duration, suspect cardiac enlargement
• Palpate for abnormal pulsations or vibrations

  At apex, left sternal border, and base
• Normal precordium palpation


  No pulsations/vibrations palpated
• Abnormal precordium palpation


  A thrill, which feels similar to a purring cat or a pulsation is usually associated with grade IV or higher murmur